MEDICARE: COASTAL QUALITY CARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD1600X	Developmental Disabilities Clinic/Center

General Provider Information

NPI Number	:	1295332468
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL QUALITY CARE LLC

Provider Business Mailing Address
First Line	:	PO BOX 16166
Second Line	:
City	:	SAINT PETERSBURG
State	:	FL
Zip	:	33733-6166
Country	:	US
Telephone Number	:	727-967-6797
Fax Number	:

Provider Business Practice Location Address
First Line	:	6625 23RD CIR N
Second Line	:
City	:	SAINT PETERSBURG
State	:	FL
Zip	:	33702-5609
Country	:	US
Telephone Number	:	727-967-6797
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TARICA-TORY MCCRAY
Credential	:	APRN
Telephone Number	:	727-967-6797

Provider Enumeration Date	:	10/01/2020
Last Update Date	:	10/01/2020

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